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Important: Prior to submitting your information, please make a copy for your records
Connecticut General Statute and CCSU requires the following information for all matriculated students (full and part time).
Please submit this form to Student Wellness Services-University Health Services no later than July 15 for the Fall semester
and December 15 for the Spring semester. Failure to submit the required form will result in a health hold on your student account.
Proof of immunity to Measles (Rubeola): you must provide proof of one of the following:
Two measles or two MMR immunizations (1st dose on or after your 1st birthday; second dose at least 28 days later); OR
Lab results showing a positive measles titer (blood test) Please submit a copy of the test results with health form.
Proof of immunity to Rubella: you must provide proof of one of the following:
Two rubella or two MMR immunizations (1st dose on or after your 1st birthday; second dose at least 28 days later); OR
Lab results showing a positive rubella titer (blood test) Please submit a copy of the test results with health form.
Proof of immunity to Mumps: you must provide proof of one of the following:
Two mumps or two MMR immunizations (1st dose on or after your 1st birthday; second dose at least 28 days later); OR
Lab results showing a positive mumps titer (blood work) Please submit copy of the test results with health form.
Proof of immunity to Varicella (chicken pox): you must provide proof of one of the following:
Two varicella immunizations (second dose at least 28 days after the first dose); OR
Lab results showing a positive varicella titer (blood test) Please submit copy of the test results with health form.
Certification of confirmed cases of measles, mumps, rubella & varicella by a licensed health care provider may be
submitted in lieu of the above. (signed note from a medical provider).
Proof of Meningococcal vaccination (Menactra) is required for all residential students prior to room assignment. No
student may move into campus housing without proof of this vaccine. The vaccine must have been administered within
five years before enrollment.
Hepatitis B: The American College Health Association, the Connecticut Public Health Department, and the Centers for
Disease Control recommend students be immunized against Hepatitis B (while not required it is strongly recommended).
IMMUNIZATION EXEMPTIONS
Students born prior to January 1, 1957 are exempt by age from the measles, mumps, and rubella requirement.
Students born prior to January 1, 1980 are exempt by age from the varicella requirement.
Vaccination waivers for religious or medical reasons are acceptable and can be found at www.ccsu.edu/healthservice/forms.
Exemptions for either medical or religious reasons subjects the individual to exclusion from
campus in the event of an outbreak of a disease for which immunizations are required.
Please check your Central Pipeline account no sooner than 3 business days after submitting the required
information. Your Central Pipeline account will indicate the MISSING information under the “Registration Status”
Section. If you have a health hold and nothing is indicated as to what is missing, we have not received ANY
information for you. You may mail, fax, drop off (page 2 of form) or email to sws@ccsu.edu. Please only submit
ONE copy of your form to avoid processing delays. Thank you.
Reminder: Prior to submitting your information, please make a copy for your records
Connecticut State University Student Health Services Form FOR OFFICE USE ONLY
Complete Missing: _______________________
Semester Beginning School Fall Spring of __________
PLEASE RETAIN A COPY OF THIS HEALTH FORM FOR YOUR RECORDS BOTH SIDES/PAGES OF THIS FORM MUST BE SUBMITTED
Last Name First Name MI
6a. TB BLOOD TEST OR 6a. TB SKIN TEST Use 5TU Mantoux test only. 6b. CHEST X-RAY Required within the past 6c. TB TREATMENT
Interferon-gamma 12 months for a previous or current positive MEDICATION (with dose):
release assay TB skin or blood test. Copy of X-ray report
Date: MUST be attached. X-ray is not needed if
asymptomatic AND completed full course of
Result: NEG POS treatment for the positive TB test (latent TB).
Date Interpretation (If no induration, mark 0) Chest X-ray Date: Frequency:
Planted: NEG POS
Date Result: Normal Abnormal Start & Completion Dates:
Read: _______mm of induration (Attach copy of report)
Other Vaccination History (Tetanus Booster within last 10 years and Hepatitis B series are recommended if not already completed)
Hepatitis B #1 Hepatitis B #2 Hepatitis B #3 Hepatitis Titer Result:
Date Date Date Date POS NEG
Last Tetanus Booster: Td or Tdap Other Vaccination: Other Vaccination: Other Vaccination:
Date:
Signatures
I confirm that the information above is accurate.
Clinician Signature: Date:
Student consent for treatment required to be signed (If you are less than 18 years of age signatures of both the student and one parent/guardian are required)
I hereby grant permission for the Connecticut State University Health Services staff to provide me with appropriate medical and mental health treatment including medications for treatment of
illnesses/injuries and to arrange for any emergency medical care if circumstances at that time make it impossible for me to make such decisions. Furthermore, I understand that University Health
Services staff may disclose my student medical records and/or information from such records to appropriate University personnel and/or Emergency Contacts identified within my records in the event
of a health or safety situation as determined by the Student Health Services staff.
Signature of Student Signature of Parent/Guardian Date:
Connecticut State University Student Health Services Form
Page 2
PLEASE RETAIN A COPY OF THIS HEALTH FORM FOR YOUR RECORDS BOTH SIDES/PAGES OF THIS FORM MUST BE SUBMITTED
Student Name Home/Personal Email Address Student Cell Phone
Insect Environmental
Are any life threatening? Yes No Do you carry an Epi Pen? Yes No
Medications – Frequent or regular- Please list all prescriptions, natural and over the counter medications.
Is there any other medical information or health concern that we should know about? Please attach any additional information to
further explain your condition(s) or concern(s).
Central Connecticut State University Eastern Connecticut State University Southern Connecticut State University Western Connecticut State University
University Health Services University Health Services University Health Services University Health Services
1615 Stanley Street 185 Birch Street 501 Crescent Street 181White Street
New Britain, CT 06050 Willimantic, CT 06226 New Haven, CT 06515 Danbury, CT 06810
860/832-1925 Fax 860/832-2579 860/465-5263 Fax 860/465-4560 203/392-6300 Fax 203/392-6301 203/837-8594